safe administration of cytotoxic medications - GHA Central

SAFE ADMINISTRATION OF
CYTOTOXIC MEDICATIONS
GONG Cancer Care Guidelines
Next Review Date: Feb 2010
Responsibility: Gippsland Oncology Nurses Group
Purpose: Provide comprehensive, current, evidence based guidelines regarding safe
administration of cytotoxic medications to inform standardized policy and
procedure development across Gippsland. This guideline gives a brief
overview of the principles for safe administration of chemotherapy and
follows the WorkSafe Victoria guide 2003 (see references).
Desired Outcome: Raise awareness of the topic of safe administration of cytotoxic
medications in cancer care and thereby promote best practice.
Nursing staff are responsible for the safe administration of cytotoxic medications to patients as
ordered by a medical officer. This includes checking that it is safe to administer the cytotoxic
medications to the patient, confirming that the cytotoxic medication labelling is correct for the
patient's treatment and ensuring that the drugs are administered in line with best practice.
Cytotoxic medications will be administered by Division 1 Registered nurses, in a safe manner,
which complies with the WorkSafe Guidelines 2003.
1. ORDERING OF
CYTOTOXIC
MEDICATIONS
2. ENVIRONMENT
Refer to GONG Guideline
“Safe Handling of Cytotoxic
Substances”
www.gha.net.au/GRICS for
further information
3. NURSING
COMPETENCY
4. PATIENT
EDUCATION
A written order by a medical officer is required.
A pharmacist must validate all cytotoxic orders and medication
first, followed by two Division 1 registered nurses, checking the
patient name, UR and date of birth; name of medication, dose,
mode of delivery, frequency and time of administration,
expiration of the drug and carrier fluid; and doctor’s signature.
Areas designated for the administration of cytotoxic medications
are to have a hard floor surface, which can be thoroughly
cleaned. Carpet must not be used in these areas.
The area should be well lit, free of clutter and pedestrian traffic
kept to a minimum.
Safety requirements:
• Suction and oxygen.
• Emergency drugs and equipment.
• Spill kit.
• Personal protective equipment.
• Cytotoxic waste bin.
• Extravasation kit.
Nurses administering cytotoxic medications must be registered
in Division 1 of the Victorian Nurses Board and have completed
or are undertaking a relevant education program deemed
appropriate by the relevant unit manager of each health
service. The nurses must be able to demonstrate knowledge of
safe handling and practices associated with the administration
of cytotoxic medications to the satisfaction of the relevant unit
manager of each health service.
Before administration of cytotoxic medications, patients are to
receive appropriately designed and delivered education,
including both verbal and take home information on the
medication, side effects and self care actions required.
SAFE ADMINISTRATION OF CHEMOTHERAPY Gippsland Oncology Nurses Group Page 1 of 5

5. PRE-
ADMINISTRATION
ASSESSMENT
• Check the patient has given verbal or written consent for
treatment.
• Check that the appropriate patient education has been
delivered and is understood by the patient.
• Check if relevant medical history is recorded and up to date
in the patient record.
• Check patient’s recent blood test results including Full Blood
Examination and Biochemistry.
• Assess side effect profile against patient’s current
medication.
• Record baseline vital signs.
• Discuss all abnormal results with consulting physician.
• Review the relevant cytotoxic medication protocol at
http://www.cancerinstitute.org.au
• Assess venous access.
6. PRINCIPLES OF CARE OF CHEMOTHERAPY ADMINISTRATION
6.1. Management of
peripheral venous
access
6.2. Management of
Central Venous
Access Devices
Manage central venous
access devices according to
the relevant GONG “Cancer
Care Guidelines for PICCs,
Ports and Hickman’s
catheters.”
www.gha.net.au/GRICS
Ensure patency of peripheral venous access before and during
administration of cytotoxic medication by checking:
• Flashback or aspiration of blood.
• Ability to easily infuse solutions.
• Absence of erythema, swelling and pain.
• Use a newly sited cannula wherever possible.
• Ensure there has been no venepuncture performed at the
infusion site or proximal, in the previous twelve hours.
• Avoid joints or bony prominences.
• Do not use the arm on the side of an axillary lymph node
dissection.
• Select the smallest gauge intravenous catheter that is
appropriate for the volume of fluid to be administered.
• Select a vein large enough to cope with the volume of fluid
to be administered.
• Do not give vesicants into the cubital fossa via a peripheral
cannula.
• Secure the cannula so that it cannot become dislodged.
• Ensure that the IV site can be clearly visualised.
Ensure patency of central venous access devices before and
during administration of cytotoxic medication by:
• Aspiration of blood.
• Ability to easily infuse solutions.
• Absence of erythema, swelling and pain.
Continuous infusions of vesicant drugs must be administered
via a central venous access device.
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6.3. Management during
intravenous
administration
6.4. Management of
vesicant medications
A VESICANT
MEDICATION IS capable
of causing pain,
inflammation, blistering and
ulceration of skin that leads
to tissue necrosis. The final
result may be dystrophy or
atrophy, scar formation,
damage to nerves, muscles
and loss of limb function if
severe
Refer to Appendix 1 for
identification of vesicant
medications
6.5. Management of
subcutaneous/intra
muscular cytotoxic
medications
6.6. Management of
topical cytotoxic
medications
6.7. Management of oral
cytotoxic
medications
• Intravenous equipment must include syringes and lines with
luer lock connections, lines with one-way or non-return
valves and add-a-lines. Needle-less administration systems
must be used.
• Back-priming technique is to be used, with intravenous adda-lines,
before and after administration of cytotoxic
medications.
• A multiple access connection (eg. 3-way tap) should be
used on chemotherapy lines in case of hypersensitivity
reaction.
• Cytotoxic medications must be handled at waist level.
• Monitor patient closely during cytotoxic medication
administration according to relevant protocol.
• Following completion of administration of cytotoxic
medications equipment must be disposed of, intact, into the
cytotoxic waste bin.
• Always wash hands after completion of administration of
cytotoxic medication.
Administration of vesicant medications must be according to the
following principles:
• Vesicant medications must be administered before nonvesicant
medications.
• Continuous infusions of vesicant medications must be
administered via a central venous access device.
• Short, peripheral infusions of vesicant medications must be
via a fast flowing intravenous line, not through infusion
pumps.
• Chemotherapy nurse must remain with the patient at all
times during administration of vesicant medications for
rapid assessment of extravasation.
General principles of safe handling and administration of
cytotoxic medications needs to be followed including wearing
Personal Protective Equipment and disposal of waste (syringes)
into a cytotoxic bin.
General principles of safe handling and administration of
cytotoxic medications needs to be followed including wearing
Personal Protective Equipment (Gloves) and use of a disposable
spatula for application of cytotoxic topical agents and disposal
of waste (spatula and gloves) into a cytotoxic bin.
• Do not crush or break cytotoxic tablets/capsules for any
reason.
• Instruct patient to swallow tablet/capsule whole.
• All medications will be provided from pharmacy in
appropriately labelled “caution-cytotoxics” containers with
instructions.
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6.8. Documentation • Ensure all appropriate documentation is recorded in the
patient’s medical record.
• Ensure all drug orders are signed by two registered nurses
administering and checking the cytotoxic medications.
• Documentation should be done in real time, not at the end
of the shift.
REFERENCES
1. American Society of Health-System Pharmacists. (2002). ASHP guidelines on preventing medication
errors with antineoplastic medications. Am J Health-Syst Pharm. 59:1648-68.
2. Bayside Health. (2005). Guidelines for safe handling of cytotoxic drugs. Bayside Health.
3. British Columbia Cancer Agency. (2006). Policy: Chemotherapy process. British Columbia Cancer
Agency.
4. Cancer Institute NSW. (2005). Management of cytotoxic drugs and waste.
http://www.cancerinstitute.org.au/
5. Cancer Nurses Society of Australia. (2003). Chemotherapy Position Statement on the minimum
education and safety requirements for nurses involved in the administration of cytotoxic drugs. CNSA.
6. Labuhn, K., Valanis, B., Schoey, R., Loveday, K. & Vollmer, W.M. (1998). Nurses’ and pharmacists’
exposure to antineoplastic drugs: findings from industrial hygiene scans and urine mutagenicity tests.
Cancer Nursing. 21(2): 79-89.
7. Latrobe Regional Hospital. (2005). Cytotoxic substances-Administration of cytotoxic drugs protocol.
Latrobe Regional Hospital.
8. Latrobe Regional Hospital. (2006). Cytotoxic substances-Administration of cytotoxic drugs policy.
Latrobe Regional Hospital.
9. Latrobe Regional Hospital. (2006). Cytotoxic substances-safe handling policy. Latrobe Regional
Hospital.
10. Peter MacCallum Cancer Centre. (2004). Disposal of cytotoxic waste. Policy and procedure. Peter
MacCallum Cancer Centre.
11. Peter MacCallum Cancer Centre. (2005). Administration and management of cytotoxic drugs. Policy
and procedure. Peter MacCallum Cancer Centre.
12. SHPA Committee of Specialty Practice in Oncology. (2005). SHPA Standards of practice for the safe
handling of cytotoxic drugs in pharmacy departments. Journal of Pharmacy Practice and Research.
Vol 35 (1): 44-52.
13. WorkSafe Victoria. (2003). Handling cytotoxic drugs in the workplace. WorkSafe Victoria.
SAFE ADMINISTRATION OF CYTOTOXIC MEDICATIONS Gippsland Oncology Nurses Group Page 4 of 5

APPENDIX 1
CLASSIFICATION OF CYTOTOXIC AGENTS BY
EXTRAVASATION POTENTIAL
Cancer Institute NSW. (2005). Classification of cytotoxic agents by extravasation potential
http://www.cancerinstitute.org.au/
1. Vesicants:
Capable of causing pain, inflammation, blistering and ulceration of skin that leads to tissue necrosis. The
final result may be dystrophy or atrophy, scar formation, damage to nerves, muscles and loss of limb
function if severe.
1.1 Amsacrine
1.2 Cisplatin>0.4mg/ml
1.3 Dactinomycin
1.4 Daunorubicin
1.5 Doxorubicin
1.6 Epirubicin
1.7 Idarubicin
1.8 Mitomycin C
1.9 Mitoxantrone
1.10 Mustine
1.11 Vincristine
1.12 Vinblastine
1.13 Vindesine
1.14 Vinorelbine
1.15 Paclitaxel
2. Irritants:
Capable of causing tissue inflammation, irritation and pain extending to phlebitis but without leading to
tissue damage or necrosis.
2.1 Busulphan
2.2 Docetaxel
2.3 Cisplatin
2.4 Etoposide
2.5 Carmustine
2.6 Fotemustine
2.7 Dacarbazine
2.8 Gemcitabine
2.9 Liposomal Doxorubicin
2.10 Melphalan
2.11 Liposomal Daunorubicin
2.12 Oxaliplatin
2.13 Streptozocin
2.14 Treosulfan
2.15 Teniposide
2.16 Trimetrexate
3. Non Irritants (Neutrals):
3.1 Asparaginase
3.2 Etoposide phosphate
3.3 Bleomycin
3.4 Fludarabine
3.5 Carboplatin
3.6 Fluorouracil
3.7 Cladribine
3.8 Ifosfamide
3.9 Cyclophosphamide
3.10 Irinotecan
3.11 Cytarabine
3.12 Methotrexate
3.13 Estramustine
3.14 Pegaspargase
3.15 Pentostatin
3.16 Thiotepa
3.17 Raltitrexed
3.18 Topotecan
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